基于人群倾向评分分析的急性胆囊炎早期和延迟胆囊切除术的手术效果比较。

Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: a population-based propensity score analysis.

机构信息

*Sunnybrook Research Institute, Sunnybrook Health Sciences Center †Li Ka Shing Knowledge Institute, St Michael's Hospital; and ‡Institute for Clinical Evaluative Sciences, Toronto, Canada.

出版信息

Ann Surg. 2014 Jan;259(1):10-5. doi: 10.1097/SLA.0b013e3182a5cf36.

DOI:10.1097/SLA.0b013e3182a5cf36

PMID:23979286

Abstract

OBJECTIVE

To compare the operative outcomes of early and delayed cholecystectomy for acute cholecystitis.

BACKGROUND

Randomized trials comparing early to delayed cholecystectomy for acute cholecystitis have limited contemporary external validity. Furthermore, no study to date has been large enough to assess the impact of timing of cholecystectomy on the frequency of serious rare complications including bile duct injury and death.

METHODS

This is a population-based retrospective cohort study of patients emergently admitted to hospital with acute cholecystitis and managed with cholecystectomy over the period of April 1, 2004, to March 31, 2011. We used administrative records for the province of Ontario, Canada. Patients were divided into 2 exposure groups: those who underwent cholecystectomy within 7 days of emergency department presentation on index admission (early cholecystectomy) and those whose cholecystectomy was delayed. The primary outcome was major bile duct injury requiring operative repair within 6 months of cholecystectomy. Secondary outcomes included major bile duct injury or death, 30-day postcholecystectomy mortality, completion of cholecystectomy with an open approach, conversion among laparoscopic cases, and total hospital length of stay. Propensity score methods were used to address confounding by indication.

RESULTS

From 22,202 patients, a well-balanced matched cohort of 14,220 patients was defined. Early cholecystectomy was associated with a lower risk of major bile duct injury [0.28% vs 0.53%, relative risk (RR)=0.53, 95% confidence interval [CI]: 0.31-0.90], of major bile duct injury or death (1.36% vs 1.88%, RR=0.72, 95% CI: 0.56-0.94), and, albeit non-significant, of 30-day mortality (0.46% vs 0.64%, RR=0.73, 95% CI: 0.47-1.15). Total hospital length of stay was shorter with early cholecystectomy (mean difference 1.9 days, 95% CI: 1.7-2.1). No significant differences were observed in terms, open cholecystectomy (15% vs 14%, RR=1.07, 95% CI: 0.99-1.16) or in conversion among laparoscopic cases (11% vs 10%, RR=1.02, 95% CI: 0.93-1.13).

CONCLUSIONS

These results support the benefit of early overdelayed cholecystectomy for patients with acute cholecystitis.

摘要

目的

比较急性胆囊炎早期和延迟胆囊切除术的手术结果。

背景

比较急性胆囊炎早期和延迟胆囊切除术的随机试验具有有限的当代外部有效性。此外，迄今为止，没有一项研究的规模足以评估胆囊切除术时机对包括胆管损伤和死亡在内的严重罕见并发症发生率的影响。

方法

这是一项基于人群的回顾性队列研究，研究对象为 2004 年 4 月 1 日至 2011 年 3 月 31 日期间因急性胆囊炎紧急住院并接受胆囊切除术治疗的患者。我们使用了加拿大安大略省的行政记录。患者分为 2 个暴露组：在指数入院的急诊科就诊后 7 天内接受胆囊切除术的患者（早期胆囊切除术）和胆囊切除术延迟的患者。主要结局是胆囊切除术后 6 个月内需要手术修复的主要胆管损伤。次要结局包括主要胆管损伤或死亡、胆囊切除术后 30 天死亡率、开放性方法完成胆囊切除术、腹腔镜病例中转开腹手术和总住院时间。采用倾向评分法来解决指示性混杂问题。

结果

从 22202 例患者中，确定了一个匹配良好的 14220 例患者的队列。早期胆囊切除术与较低的主要胆管损伤风险相关[0.28%比 0.53%，相对风险（RR）=0.53，95%置信区间（CI）：0.31-0.90]，主要胆管损伤或死亡的风险也较低[1.36%比 1.88%，RR=0.72，95%CI：0.56-0.94]，尽管无统计学意义，但 30 天死亡率也较低[0.46%比 0.64%，RR=0.73，95%CI：0.47-1.15]。早期胆囊切除术的总住院时间较短（平均差异 1.9 天，95%CI：1.7-2.1）。在开放性胆囊切除术（15%比 14%，RR=1.07，95%CI：0.99-1.16）或腹腔镜病例中转开腹手术（11%比 10%，RR=1.02，95%CI：0.93-1.13）方面，两组间无显著差异。